Critical injury care is among the biggest success stories of British military operations in Iraq and Afghanistan. A range of measures, from mandating the use of tourniquets to employing Chinook helicopters to deliver medical emergency response teams (MERT), has brought a higher echelon of care closer to the battlefield than ever before. AW&ST Contributing Editor Angus Batey discussed the challenges of the transition from combat to contingency with the surgeon general of the U.K. Defense Ministry, Air Marshal Paul Evans (far left, above).

Air Marshal Paul Evans

Surgeon General, U.K. Defense Medical Services

Born: 1954

Education: Qualified as medical doctor, 1978; Diploma in aviation medicine, 1987; RAF Staff College, 1996; Royal College of Defense Studies, 2004.

Background: Commissioned into the medical branch of the RAF in 1975; positions include medico-legal advisor to the director general of RAF Medical Services, medical officer for clinical policy and healthcare director, Surgeon General's department.

Defense Technology: How can the medical gains made in Afghanistan be sustained once combat operations end?

Evans: Defense medical services are at their peak in times of war and major conflict. You will always get an element of skill fade [afterward]. What you've got to do is minimize it. And I think there are a number of ways to do that. The first thing is you must log lessons learned, and, while I can't replicate Afghanistan in the U.K., we have to look at what else might be available to maintain the skills as best we can.

What role would simulation play in this?

Simulation is very important—both individual techniques, such as learning to sew arteries and veins together, and collectively. So running exercises is one way, maybe in a tented light-maneuver environment. But we already have some people working in London hospitals, for instance, and will look at opportunities to deploy our people [within the civilian National Health Service (NHS)], when they are not deployed elsewhere.

There are examples of frontline requests for specific pieces of relatively inexpensive, off-the-shelf equipment sometimes being delivered within hours. How has defense medicine managed to streamline the acquisition process?

It's about the ability to recognize the important things in-theater. People all along the care chain are always asking if something could have been done better. That is then fed from [Camp] Bastion [the main British base in Afghanistan] back to the U.K., to the medical directorate and our defense professors. If the argument looks valid and if there are mistakes, we'll adapt. It can work through the system very quickly.

Are MERT and CCAST (critical care air support team, currently delivered on C-17 and C-130 platforms) capabilities theater-specific, or will they be retained?

I would expect them to be retained. Of course, we have air superiority in Afghanistan, and may never have it in a new environment, so we must not be dogmatic in assuming that what we've done in Afghanistan applies everywhere else. But the principles will remain: very good immediate care from the team medic and combat medical technician, pushing forward the advanced-resuscitation capability, and the ability to extract to a reasonable place of safety. It's then about applying the principles to the new environment you are working in.

The U.S. Dustoff casualty evacuation helicopters are not armed. MERT carries RAF regiment personnel onboard, who secure the scene while the MERT crew work. Why is your approach different?

MERT uses a bigger helicopter and is therefore more vulnerable. It always flies with Apache helicopter support, but it probably wouldn't go into as hot an environment as a Dustoff or a Pedro [rescue helicopter]. We carry regiment guys, because you don't want your medical people to be damaged, as they've got to provide the care. I think that the Americans will start to develop a MERT capability of their own, but it will be part of a spectrum of capability that you'd look to provide in a different environment. The use of reservists, whose normal jobs may be in the NHS, is another area where defense medicine seems to be ahead of the rest of the military.

Do you see those relationships altering post-Afghanistan?

I think there is a careful balance that has to be applied. Clearly, the whole principle of the regular is that he is always at high readiness, whereas the reservist is more to reinforce the regulars as the operation sustains. That is still the principle. But we are going to have to subtly [ask], is there then a wedge of reservists who are on a higher level of readiness than the standard reserve? That's a work-in-progress as we speak.

Some of your combat care techniques are now in use by civilian emergency response teams, and areas such as prosthetics have seen improvements based on combat experience. Do you see that read-across continuing as well?

That's the plan. “Status” is a heavy word, but the status defense medicine now has within U.K. medicine is such that it will be our fault if we let that fall off.